5816
CHESS
A Community Health
and
Environmental Surveillance
System
Wilson B. Riggan, Douglas I. Hammer, John F. Finklea
V. Hasselblad, Charles R. Sharp, Robert M. Burton
and Carl M. Shy
Presented at Sixth Berkeley Symposium
on Mathematical Statistics and Probability
Biology - Health Section, Part III
Monday, July 19, 1971
Berkeley, California
Division of Health Effects Research
National Environmental Research Center
Environmental Protection Agency
Research Triangle Park, North Carolina 27711
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CHESS INTRODUCTION
The Community Health and Environmental Surveillance System (CHESS) relates
community health to environmental quality. CHESS, consists of a series
of epidemiologic studies in sets of communities representing consistent
exposure gradients for common environmental pollutants. The keystone
of the CHESS program is the coupling of sensitive health indicators to
comprehensive environmental monitoring in sets of communities representinq
a consistent pollutant exoosure gradient, thus allowinq temnoral and
spatial replications of dose-response studies.
EPA health research needs are practical and nroblem oriented. CHESS
research is thus pragmatic, and its goals are threefold:
First, to evaluate existing environmental standards,
Second, to quantitate pollutant burdens in exposed populations, and
Third, to quantitate health benefits of pollutant control.
CHESS HISTORY AND OVERVIEW
Obligations to prepare air quality criteria documents end set air
quality standards were legislated by the Clean Air Act of 1967. CHESS
evolution began the fiscal year of 1968 (FY68) with the health apprai-
sal of air quality standards (Figure 1). The CHESS concept developed
simultaneously with the growth of a multidisciplinary "critical mass"
in FY 1969. Growth for this single medium approach (air) was by
initial demonstration of both health indicators and ironitorinq within
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established areas, and their subsequent expansion into new areas (FY 1970-71)
The recent creation of the Environmental Protection Agency signalled a
more comprehensive and, now, multimedia approach to environmental hazards.
CHESS-will be fully operational to assess air pollution effects by FY 1973
and to assess multimedia toxic substances by FY 1975. Present CHESS
operations consist of three basic, integrated functions; namely, Data
Collection, Bloenvironmental Measurements, and Information Synthesis,
supported by a fourth function, Research and Development and coordinated
by a fifth function, Program Management, (Figure 2). Simultaneous environ-
mental monitoring and measurement of sensitive health indicators in
community area sets are the fundamental CHESS components.
CHESS AREA SETS
CHESS area sets consist of groups of three or four communities representing
an exposure gradient for a pollutant, but similar 1n climate and socio-
economic traits. Each community within an area set is a defined middle
class residential segment of a city containing three or four elementary
schools (500 - 1000 children per school) and often a secondary school.
CHESS pollutant gradients are as follows:
A. Particulate gradient with low S02 (3 Southeast cities)
B. S02 gradient with low particulates (Utah communities)
C. Combined S02 and particulate gradient (N. Y. City active,
Chicago planned)
D. Photochemical oxidant gradient (Los Angeles Basin)
E. NOX gradient (Chattanooga)
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F. Trace element and S02 gradient (Western metal smelter
communities)
CHESS EXPOSURE MONITORING
Neighborhood monitoring stations are sited to provide a representative
estimate of pollutant exposure for the study population. Supplemental
home monitoring of tap water, household dust and soil samples permit even
more intimate estimates of environmental trace substance exposure. Study
sub.iects usually live within a 1 to 1.5 mile radius of monitorina stations.
Topography, emission sources, and local land use are all considered when
placing stations. The inlet of the monitoring instruments is usually
placed at head level and sheltered from uncommon proximate pollution
sources. The CHESS System^ monitors for the following environmental
exposures:
A. Present CHESS system, all stations
1. Total suspended particulates (daily)
a. Sulfates (daily)
b. Nitrates (daily)
c. Organic (monthly)
d. Benzapyrene (monthly)
e. Trace metals (monthly)
2, Respirable particulate (daily)
3. Dustfall (monthly)
a. Trace metals (monthly)
4. Sulfation - (Pb 02 monthly)
5. Twenty-four hour S02 (daily)
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B. Present system, some stations
1. Two hour soiling index
2. Twenty-four hour N02
3. Continuous N02
4. Continuous S02
5. Continuous oxidants
C. CHESS - CHAMP: Community Health Ambient Monitoring
Program, prototype field testing.
1. Continuous NO-N02
2. Continuous SC"2
3. Continuous oxidants
4. Hydrocarbons
5. Mobile unit-replication
6. Wind speed and direction
»
CHESS - CHAMP (The Community Hea'ith Ambient Monitoring Program) is
currently collecting daily twenty-four hour samples and monthly samples for
gases and particulates at 30 environmental monitoring stations. Real time
pollutant measurements can accurately relate short-term environmental
variations to acute response health indicators, distinguishing "peak"
exposure effects from 24 hour average effects.
Continuous monitors operate in some CHESS - CHAMP stations and a prototype,
automatic-data-acquisition, continuous monitoring station with magnetic tape
storage and "on call" telemetric output is now being field tested. "On-call"
telemetry permits routine instrument performance checks, daily data
processing and thus immediate access* to data during air pollution episodes.
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Duplicate sampling of the environment and frequent calibration of all
instruments are systematically obtained to ensure accurate and consistent
instrument performance in the CHESS - CHAMP system.
CHESS HEALTH INDICATORS
Relationships between human diseases and pollution exposures are neither
simple nor fully understood. However, one may conveniently think of a
five stage biologic response spectrum of increasing severity:
(1) a tissue pollutant burden unassociated with other biological changes,
(2) physiologic changes of uncertain significance, (3) physiologic disease
sentinels, (4) morbidity and (5) mortality (Figure 3). CHESS utilizes
health indicators which reflect this entire spectrum. The following in-
dicators of acute and chronic responses are studied in community surveys
as well as in pre-enrolled panels of subjects.
A. Indicators of acute exposure (<24 hours)
•
1. Reversible pulmonary function changes
2. Acute irritation symptoms
3. Frequency and severity of asthma attacks
4. Aggravation of chronic respiratory disease (CRD) symptoms
5. Aggravation of cardiac symptoms
6. Daily mortality rates
B. Indicators of chronic exposure (>24 hours)
1. Pollutant burdens (man as an environmental dose integrator)
2. Impairment of lung function
3. . Absenteeism (no longer used)
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6
4. Prevalence of chronic respiratory disease (CPD).
5. Frequency of lower respiratory disease (LRD).
6. Incidence of acute respiratory disease (ARD).
7. Mortality studies.
Comparison of similar groups is insured by obtaining covariate information
such as age, sex, race and smoking status. These study desion covariates
all relate to morbidity; failure to measure and adjust for them could
cause serious confounding effects. They are summarized as follows:
A. Demographic - age, sex, ethnic groun, socioeconomic,status,
reporting bias
B. Exposure - diet, drinking water, smoking habits, occupation,
migration, indoor-outdoor gradients, daily movement
C. Special Risk - temporary such as age, pregnancy or illness;
permanent such as alpha-1-antitrypsin deficiency or serum
IgE levels.
•
CHESS STUDY STRATEGIES
Selection of CHESS area sets and oollutant exposure gradients were dic-
tated by the existence of air quality criteria documents for narticulate
matter, sulfur oxides, nitrogen oxides, ohotochemical oxidants, hydro-
carbons and carbon monoxide (CO), published by the National Air Pollution
Control Administration. Area sets for individual oollutants were selected
from existing exposure monitoring data. However, a CHESS set to measure
the effects of exposure to CO was not established because short-term CO
effects are more precisely studied in controlled exposure chambers, and
long-term CO effects are likely to be confounded with the effects of
other vehicle emissions products. Nor has an area set with a consistent CO
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gradient been found.
Middle class neighborhoods are chosen because they represent a larae
proportion of the population, have a more homogeneous family and social
class distribution, and are migrationally stable, thus providing a higher
likelihood of long-term participation. Family participants in the surveys
for acute upper, acute lower, and chronic respiratory diseases and panels
for episodes are recruited from elementary school enrollments in CHESS
neighborhoods. Subjects for the asthma, cardiac, and chronic respiratory
disease panels are obtained from prevalence survey results and from patient
listings of from private physicians. As indicated, our broad data acquisition
techniques vary in the frequency and the type of response they measure. The
following methods are currently used:
1. Exposure monitoring
2. Single-time questionnaire
3. Weekly diaries
4. Bi-weekly telephone contact
5. Spirometry in schools
6. Telephone contact during alerts
7. Tissue collection
8. Vital statistics
CHESS programs will operate from three to five years in selected areas.
Measurement of sensitive health indicators over a period of increased air
pollution control is an optimal way to quantitate the health benefits
of this control.
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CHESS data collection for FY 71 alone will yield a total of 40 x 106
health indicator and 3 x 105 air determination characters for data pro-
cessing (Table 1). Rapid reporting is the rule because high priorities
are placed on our study results. Recent CHESS findings span the entire
biologic response spectrum and are outlined and referenced in Appendices
I and II.
Research goals are essential for optimal CHESS functioning and play a
critical role in our development. CHESS research and development goals
are threefold: (1) to refine exposure monitoring, (2) to improve
statistical procedures and (3) to develop and test more sensitive health
indicators. Current and future CHESS health-indicator research is
outlined in Appendix III.
Estimating environmental exposure-doses has always been a problem. In
health studies of multimedia toxic substances, this problem increases.
Pollutant burden studies of biological accumulators such as pets, plants,
and wildlife in addition to humans should be utilized for appropriate
metals, pesticides, synthetic organic materials and selected gaseous pollutants.
Sample sets of tap water, housedust and soil from CHESS panel families
provide intimate information about trace metal exposure when coupled to
neighborhood environmental monitoring and dietary metal surveys. Personal
monitors for all pollutants would permit the best pollutant dose estimates
for individual study subjects.
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We have addressed our remarks to the central questions of this conference,
namely, what pollutants to measure, what health indices to measure, avail-
able methods 4'f obtaining both types of data, and available study strategies.
CHESS permits a systematic, yet flexible, approach to these problems and has
already produced answers to some of them.
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Table 1. FY 1971 CHESS Program - Data Collection Summary
Indicator
CRD
LRD
ARO
Pulmonary
Function
Asthma
Elderly
Irritation
Symptoms
Pollutant
Burdens
Frequency
biyearly
biyearly
biweekly
tri annually
weekly
weekly
tri annually
biyearly
Population
30 ,000
30,000
15,000
5,000
300
450
12,000
6,000
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Morbidity
Adverse
Health
Effects
Physiologic Sentinels
of Disease
Physiologic Changes of
Uncertain Significance
Pollutant Burdens
Proportion of Population Affected
Figure 3 Human Biological Response
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Appendix I CHESS - Recent Findings
A. Pollutant burdens
1. Roadside gradients of Cd, Pb and Zn £6]
2. As, Cd, Cu, Pb, Ag and Zn in household dust [36]
3. Environmental exposure to As, Cd and Pb reflected
in hair and consistent over time and within
individuals [19,20]
4. Hg in placentas, Cd in cord blood [35]
5. PCB highest *r\ urban whites [15]
6. Inter laboratory and interwash variation neglinible for
hair Cd, Pb and Zn determinations [21]
B. Physiological changes of uncertain significance
1. Hair and blood Pb correlate (.40) over an exposure gradient [19]
2. Urinary Cd does not increase with age [18]
3. Eye irritation highly correlated with oxidant exnpsure [22]
C. Physiologic sentinels of disease
1. Pulmonary function in children decreased after S0x»
particulate and NOX exposure [30,32,33]
2. Pulmonary function in adults decreased a"ter NOX exposure [35]
3. Systolic BP in adults 40 may be increased after rd exposure,
but not diastolic BP or cholesterol [11]
D. Morbidity
1. ARD and LRD in children after exposure in MOX [25,32]
2. CRD symptoms in young adults but not adolescents more freouent
after exposure to SO and parftculates but not 0 [35]
3. Respiratory and eye irritation symptoms induced fly
acute urban air pollution exposure [4]
4. Asthma attacks more frequent after nitrate, SOX, and
particulate exposure [3]
5. Cd not increased in toxemia of pregnancy [7]
6. No observed effect of chronic oxidant exposure on
epidemic influenza in school children [26]
7. Epidemic!ogic evidence linking Cd to hypertension is weak
when critically reviewed [18]
E. Mortality
1. No long term effect of As, Pb on survival of "P!eal Conort" [24]
2. No long term effect of acute MOX exposure on survival [17]
3. No effect of water hardness and no consistent effect of
' Cd on CVD mortality [27]
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4. Possible relationship between chronic urban air pollution
exposure and carefully adjusted mortality rates in
Chicago and Philadelphia 127]
5. Large temperature, influenza and socioeconomic effects
on daily mortality [2]
F. Associations with cigarette smoking
1. Increases in ARD, LRD freauency [14]
2. Higher influenza attack rates [16]
3. Impaired persistence of HI antibody [13]
4. Decreased ventilatory function
5. CRD symptoms in early adolescence
6. Refactiveness to acute air pollution episodes [4]
7. No change in ARD, influenza, or antibody persistence
among children if parents smoke £10]
G. Some Recent Reviews
1. General Overview of CHESS Research [29]
2. Overview of Human Pollutant Burden Research [12]
3. Air Pollution Episodes - Guide for Health Departments
and Physicians [5]
4. Review of Arsenic Health Effects [1]
5. Review of Beryllium Health Effects [28]
6. Review of Cadmium Health Effects [18]
7. Reviews of Environmental Lead and Human Health [8,31]
8. Plasticizers in the Environment [23]
9. Environmental Hazards of Optical Brighteners [9]
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Appendix II CHESS References
[1] R. W. BUECHLEY, "The paths of arsenic pollution." CRB In-House
Technical Report, September, 1970.
[2] R. M. BUECHLEY, L. E. TRUPPI. J. VAN BRUGGEN. "Heat island - death
island," CRB In-House Technical Report. August, 1971.
A. A. COHEN, S. M. BROMBERG, R. W. 3UECHLEY, L. T. HEIDERSCHEIT
and C. M. SHY, "Asthma and air pollution from a coal fired power
plant," American Journal and Public Health (in press).
[4] A. A. COHEN. C. J. NELSON S. M. BROMBERG. M. PRAVDA and E. F. FERRAND.
"Symptom reporting during recent publicized and unpublicized air
pollution episodes," Abstract, 99th Annual APHA Meeting, Minneapolis,
October, 1971.
[5] A. A. COHEN. C. M. SHY, F. B. BENSON. H. B. RIGGAN. V. A. NEWILL and
J. F. FINKLEA, "Air pollution episodes - a guide for health departments
and physicians," HSMHA Health Reports, 86(6): 537-550, (June), 1971.
[6] J. P. CREASON. 0. McNULTY. L. T. HEIDERSCHEIT. D. H. SWANSON and
R. H. BUECHLEY, "Roadside gradients in atmospheric concentrations of
cadmium, lead and zinc," Proceedings of the Fifth Annual Conference
on Trace Substances in Environmental Health, (in press).
[7] J. P. CREASON. J. F. FINKLEA and D. I. HAMMER, "Relationship of
cadmium to toxemia of pregnancy," In-house Technical Report,
June, 1970.
[8] R. E. ENGEL, D. I. HAMMER. R. J. M. HORTON, N. M. LANE and L. A. PLUMLEE,
"Environmental lead and public health," EPA, Air Pollution Control
Office Publication No. AP-90. March, 1971.
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[9] J. F. FINKLEA and K. BRIDBOP.D. "Environmental hazards of optical
brighteners," CRB In-house Technical Report, September, 1971.
[10] J. F. FINKLEA,J. P. CREASON, D. I. HAMMER, S. M. PROMPEPP and
W. B. RIGGAN. "Does cigarette smoking by parents alter the ARD
immune response of ^heir children," Clinical Research 19(2):"58,
April, 1971.
[11] J. F. FINKLEA. J. P. CREASON. S. H. SANDIFER. J. E. KEIL, L. F. PPIESTEP.
D. I. HAMMER and W. B. RIGPAM, "Cadmium exposure, blood pressure and
cholesterol," Abstract, Clinical Research, Vol. 19 (1971), pp. 313.
[12] J. F. FINKLEA, D. I. HAMMER. T. A. HINNERS and r. PINKEPTON. "Hum*n
pol1utant burdens," American Chemical Society Symposium on the Peter-
mination of Air Quality, ACS Meeting, Los Angeles, Calif. (1971), (in press)
[13] J. F. FINKLEA, V. HASSELBLAD, H. B. RIGGAN, H. C. NELSON, D. I. HAMMFP
and \L A. NEHILL, "Cigarette smoking and HI response to influenza
after natural disease and immunization," Amer. Rev. Resp. Pis.
(in press).
[14] J. F. FINKLEA. V. HASSELBLAD. S. H. SANDIFFP. D. I. HAMMER and
G. R. LOWP.IMORE, "Cigarette smokinq and acute non-influenza respirator"
disease in military cadets," Amer. J. Epid. 93(6):457-462, 1971.
[15] J. F. FINKLEA, L. E. PRIESTER, J. P. CREASON. T. HAUSEP and T.
"Polychlorinated biphenyl residues in human plasma expose a
urban pollution problem," Abstract, 99th Annual APHA Meeting,
Minneapolis, October, 1971.
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[16] J. F. FINKLEA, S. H. SANDIFER and D. D. SMITH. "Cigarette smrklna
and epidemic influenza," Amer. J. Epid. 90:390-399, 1969.
[17] K. L.. GREGORY. V. F. MALINOSKI and C. R. SHARP. "Cleveland clinic
fire survivorship study, 1929-1965," Arch. Environ. Health, Vol. 18
(1969), pp. 508-515.
[18] £._ I. HAMMER. J.F. FINKLEA. J. P. CREASON, S. H. SPNDIFFP, J. E. KEIL.
L. E. PR1ESTER and J. F. STARA. "Cadmium exposure and human health
effects: Some epidemiologic considerations," Proceedings of the
Fifth Annual Conference on Trace Substances in Environmental Health,
(in press).
[19] D. I. HAMMER, J. F. FINKLEA, R. M. HENDRICKS. T. A. HINNFR5, V. P.
RIGGAN and C. M. SHY, "Trace metals in human hair as a simple epidemio-
logic monitor of environmental exposure," Proceedings of the Fifth
Annual Conference on Trace Substances in Environmental Health, (in press).
[20] D. I. HAMMER, J. F. FINKLEA, R. M. HENDRICKS, C. M. SHY and P. J. M.
HORTON, "Hair trace metal levels and environmental exposure," flmer.
J. Epid.. Vol. 93 (1971), pp. 84-92.
[21] D. I. HAMMER. K. NISHIYAMA. M. PISCATOR. R. P. HENDRICKS, J. P. CRFISPN
and T. HINNERS. "Cadmium, lead and zinc in hair - effects of environ-
mental exposure, wash techniaues and laboratory error," Abstract,
99th Annual APHA Meeting, Minneapolis, October, 1971.
[22] D. I. HAMMER, B. PORTNOY. P. F. HEHPLE, V. HASSELRLAD, C. P. SH/'PP
and P. J. M. HORTON. " A prospective dose-response study of eye
discomfort and photochemical oxidants," Abstract, 99th Annual APHft
Meeting. Minneapolis, October, 1971.
[23] T. R. HAUSER, "Plasticizers in the environment," CRP In-house
Technical Report, April, 1971.
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[24] W. C. NELSON, M. H. LYKINS, V. A. NEWILL. J. F. FINKLEA and P. I. HAMMER.
"Mortality among orchard workers exposed to lead arsenate spray: A
cohort study." DHER In-House Technical Reoort. 1970.
[25] M. E. PEARLMAN. J. F. FINKLEA, J. P. CRFASON, C.M. SHY, M. M. YPUNP
and R. J. M. MORTON. "Nitrogen dioxide and lower respiratory illness,"
Pediatrics, Vol. 47 (1971), pp. 391-398.
[26] M^E. PEARLMAN, J. F. FINKLEA, C. M. SHY, J. VAN BRUGGEN and V. A. NEWIL_L_,
"Chronic oxidant exposure and epidemic influenza," Environmental
Research, Vol. 4 (1971), pp. 129-140.
[27] C. PINKERTON. J. P. CREASON, C.M. SHY, D. I. HAMMER, R. V. BI'ECHLFY
and G. K. MURTHY," Cadmium content of milk and cardiovascular disease
mortality," Proceedings of the 5th Annual Conference on Trace Substances
in Environmental Health, (in press).
[28] C. R. SHARP, "Beryllium - A hazardous air pollutant," CRB In-house
Technica1 Report. June, 1971.
[29] C. M. SHY, J. F. FINKLEA. D. C. CALAFIORE, F. B. BENSON. W. C. NELSPN
and V. A. NEWILL, "A program of community health and environmental
surveillance (CHESS)," American Chemical Society Symposium on the
Determination of Air Quality, ACS Meeting, April 1, 1971, Los Angeles
(in press).
[30] C. M. SHY, J. P. CREASON, M. E. PEARLMAN. K. E. McCLAIN. F. B. BENSON
-and M. M. YOUNG. "The Chattanooga school children study 1: Methods,
description of pollution exposure and results of ventilatory function
testing," J. Air Poll. Control Assoc. Vol. 20 (1970), pp. 539-545.
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[31] C. M. SHY. D. I. HAMMER. H. E. GOLDBERG, V. A. NEHILL and W. C. NELSON,
"Health hazards of environmental lead," CRB In-house Technical Report.
March, 1971, (to be published).
[32] C. M. SHY. V. HASSELBLAD, R. M. BURTON, A. A. COHEN and MIMI PRAVDA.
"Is air pollution in New York City associated with decreased venti-
latory function in children," Abstract 99th Annual APHA Meeting.
Minneapolis, October, 1971.
[33] C. M. SHY. C. J. NELSON. F. B. BENSON. W. B. RIGGAN and V. A. NEPILL,
"The Cincinnati school children study: Effect of atmospheric particu-
lates and sulfur dioxide on ventilatory performance in children,"
Amer. J. Epid.. (in press).
[34] W. B. RIGGAN. R. W. BUECHLEY, J. B. VAN BRUBGEN, C. R. SHARP. L. TRUPPI,
W. C. NELSON and V. A. NEV'ILL. "Daily mortality predictor models: A
tool for environmental assessment and pollution control," Abstract.
99th Annual APHA Meeting, Minneapolis, October, 1971.
[35] Division of Health Effects Research, Unpublished data.
[36] Hammer, D.I., Finklea, J.F., Bridbord, K., Pinkerton, C., Hinners, H.A.
and Creason, J.P. Household dust as an index of environmental trace
substance exposure I, Preliminary Report, Presented at the meeting
of the Subcommittee on the Toxicology, International Conference of
the Permanent Commission and International Association on Occupational
Health, Slanchev Bryag, 20-24 September, 1971, Bulgaria (to be pub-
lished).
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1.^'.', ;,II „,..).!_ 2 60603
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Appendix III CHESS - Research and Development Goals
A. Refined Exposure Monitoring
1. Biological amplifiers (pets, plants, wildlife)
2. Personal monitors
3. Tap water, housedust, soil
B. Improved Statistical Procedures
1. Hockey-stick and other dose-response functions
2. Ridit transformation and linear models for categorical data
3. Daily mortality models
4. Analyses of truncated and censored data
5. Estimating personal exposure
6. Multivariate techniques for repeated measurements
7. Health information synthesis system
C, More Sensitive Health Indicators
1. Pollutant burdens
a. Maternal-fetal tissue sets
b. Patients - biopsy, surgery, autopsy
c. Special occupations
2. Altered physiology of uncertain significance
a. Carboxyhemoglobin
b. RBC fragility and survival
3. Physiologic heralds of disease
a. Other PF tests
b. Blood lipid patterns
c. Blood pressure
ci. Immune response
e. Exfolliative cytology
4. Morbidity
a. Aggravation of hypertension
b. Aggravation of RDS of Newborn
t
5. Mortality
a. CO and coronary disease
b- Area studies linked to SS records
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